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HomeMy WebLinkAbout7179AWORKERS' COMPENSATION DECLARATION 0 V a a i� I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C. ) PolicyNo.'3B813-368pany Industrial Indem ❑ Certified copy is hereby furnished. ®Certified copy is filed with the county building inspec- tion department. Date 4-15-81 Applicant Arciero & Sons CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you , should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 329595 Lic. Class ContractorArCiero & Sonmate 4-15-81 II am exempt from the licensing requirements as I am a architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic, or Reg. No. —Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C. ). Lender's Name Homestead Savings & Loan APPLICATION FOR BUILDING PERMIT COUNTY • " r,"� FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS LOCALITY CITY Diamond Bar ZIP NEAREST CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL USE ZONE MAP TRACT37026 1 BLOCK I LOT NO. NO. SPECIAL CONDITIONS TEL. OWNER Arciero & qQnS NO. DISTRICT GROUP FIRE PROCESSED BY ADDRESS fl`E NST. ZONE I CITY walnut, CA ZIP 91789 ARCHITECT OR TEL. STATISTICAL CLASSIFICATION APT. CONDO. ENGINEER NO. CLASS NO. DWELL. UNITS — ADDRESS 17 8 9 0 Skypark Cl Irvine SEWER MAP TEL. BK PG VALIDATION CONTRACTOR NO. LIC. ADDRESS 20001 E. Walnut NO.329595 VALUATION LIC. CITY CLASS $ % 1 Y, C A SQ. FT. N . OF NO. OF - CHECK 3 4 5 7 ISTORIES 2 SIZE FAMILIF P4&T ONE al Lender's Address 17 7 7 MTV rch i son Dr i vP -Burl I certify that I have read this application and state that40game ! above information is correct. I agree to comply with all County CA ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. Signature of Applicant or Agent Dote DESCRIPTION OF WORK NEW $ 9 6, 7 9 6. O O ADD condominiums ALTER ® FINAL REPAIR ® DATE USE OF EXISTING BLDG. D EMOL ® FINAL By APPLICANT TEL. (PRINT) NO. ADDRESS PRESENT BUILDING ADDRESS LOCALITY i.> MOVING TEL. X CONTRACTOR NO. ADDRESS REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. SET BACK PROP. LINE WIDTH FRONT P.L. SIDE P. L. P.C. Fee $ �' ,/� - ;;: 11 Permit Fee Issuance Fee Investigation Fee Total Fee SEE REVERSE FOR EXPLANATORY LANGUAGE o 67 Q " 0 L ©s